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Magnifying Endoscopy with Blue Laser Imaging improves the Microstructure Visualization in Early Gastric Cancer: Comparison of Magnifying Endoscopy with Narrow-Band Imaging

Reiko Kimura-Tsuchiya, Osamu Dohi, Yoshito Itoh. et al.

Gastroenterol Res Pract. 2017;2017:8303046. doi: 10.1155/2017/8303046. Epub 2017 Aug 30.

Backgrounds: Magnifying endoscopy with blue laser imaging (ME-BLI) for diagnosis of early gastric cancer (EGC) is as effective as magnifying endoscopy with narrow-band imaging (ME-NBI). However, there are different EGCs in microstructure visualization between ME-BLI and ME-NBI. This study aimed to clarify the pathological features of the EGCs, in which microstructure visualization was different between ME-NBI and ME-BLI.

Methods: EGCs were classified into groups A (irregular microsurface pattern (MSP) in ME-BLI and absent MSP in ME-NBI), B (irregular MSP in two modalities), or C (absent MSP in two modalities), according to the vessel plus surface classification. We compared the pathological features of EGCs between the three groups.

Results: 17, four, and five lesions could be evaluated in detail in groups A, B and C, respectively. Well-differentiated adenocarcinomas with shallow crypts were more frequent in group A than in group B (58.8 and 0%, resp.). The mean crypt depth of group A was significantly shallower than that of group B (56 ± 20, 265 ± 64 μm, resp., P = 0.0002).

Conclusions: ME-BLI could better visualize the microstructures of the EGCs with shallow crypts compared with ME-NBI. Therefore, ME-BLI could enable a more accurate diagnosis of EGC with shallow crypts.


Linked color imaging improves the visibility of various featured colorectal polyps in an endoscopist’s visibility and color difference value.

Yoshida N, Naito Y, Itoh Y. et al

Int J Colorectal Dis. 2017 Jul 19. doi: 10.1007/s00384-017-2855-z.

Purpose: Linked color imaging (LCI) by laser endoscopy is a novel narrow band light observation. In this study, we analyzed the efficacy of LCI for improving the various featured colorectal polyp’s visibility utilizing a subjective endoscopist’s visibility scoring and objective color difference (CD) value.

Methods: We retrospectively reviewed two pictures both with white light (WL) and LCI for 54 consecutive neoplastic polyps 2-20 mm in size. All pictures were evaluated by four endoscopists according to a published polyp visibility score from four (excellent visibility) to one (poor visibility). Additionally, we calculated CD value between each polyp and surrounding mucosa in LCI and WL using an original software.

Results: The mean polyp visibility scores of LCI (3.11 ± 1.05) were significantly higher than those of WL (2.50 ± 1.09, P < 0.001). The ratio of an endoscopist’s poor visibility (polyp visibility scores 1 and 2) was significantly lower in LCI (27.9%) than WL (55.6%, P < 0.001). With respect to the CD analysis, the CD value of LCI was significantly higher than that of WL (33.3 ± 13.9 vs. 20.7 ± 13.6, P < 0.001). In a subgroup analysis, the polyp visibility scores and CD values of LCI about 24 diminutive polyps (≤5 mm) were higher than those of WL (3.29 ± 0.99 vs. 2.12 ± 0.99, P < 0.001; 31.6 ± 12.8 vs. 14.7 ± 7.6, P < 0.001). Additionally, the polyp visibility scores and CD values of LCI for polyps with any location, size, histology, and morphology were significantly higher than those of WL.

Conclusions: LCI improved the various featured polyp’s visibility compared to WL in both polyp visibility scores and CD value.


Advances in image enhancement in colonoscopy for detection of adenomas.

Matsuda T, Ono A, Sekiguchi M, Fujii T, Saito Y

Nat Rev Gastroenterol Hepatol. 2017 May;14(5):305-314

High-quality colonoscopy is mandatory to prevent adenoma recurrence and colorectal cancer. In the past few years, technical advances have been developed with the purpose of improving adenoma detection rate (ADR), one of the most important validated colonoscopy quality benchmarks. Several techniques or devices are used to optimize visualization: observation techniques; add-on devices; auxiliary imaging devices; colonoscopes with increased field of view; and colonoscopes with an integrated inflatable reusable balloon. Image-enhanced endoscopy (IEE) facilitates the detection and characterization of polyps and especially nonpolypoid colorectal neoplasms. Indigo carmine is the most frequently used dye in colonoscopy as it deposits in depressed areas, improving detection of flat and depressed lesions. Virtual chromoendoscopy has emerged as an effective contrast enhancement technology without the limitation of preparing dyes and applying them through the colonoscope working channel. Narrow-band imaging (NBI) enhances the capillary pattern and surface of the mucosa using optical filters, and second-generation NBI provides a twofold brighter image than the previous system, yielding promising ADR results. Moreover, a second-generation blue laser imaging system, LASEREO, has been reported to improve not only polyp detection rate but also ADR, becoming a promising IEE modality. Herein, we describe technical advances in colonoscopy imaging and their effect on ADR.


Linked color imaging improves the visibility of colorectal polyps: a video study

Naohisa Yoshida1, Yuji Naito1, Takaaki Murakami1, Ryohei Hirose1, Kiyoshi Ogiso1, Yutaka Inada1, etc

Endoscopy International Open 2017; 05: E518–E525 Impact factor 5.196

Background and study aim: Linked color imaging (LCI) by a laser endoscope (Fujifilm Co, Tokyo, Japan) is a novel narrow band light observation. In this study, we aimed to investigate whether LCI could improve the visibility of colorectal polyps using endoscopic videos.

Patients and methods: We prospectively recorded videos of consecutive polyps 2 – 20 mm in size diagnosed as neoplastic polyps. Three videos, white light (WL), blue laser imaging (BLI)-bright, and LCI, were recorded for each polyp by one expert. After excluding inappropriate videos, all videos were evaluated in random order by two experts and two non-experts according to a published polyp visibility score from four (excellent visibility) to one (poor visibility). Additionally, the relationship between polyp visibility scores in LCI and various clinical characteristics including location, size, histology, morphology, and preparation were analyzed compared to WL and BLI-bright.

Results: We analyzed 101 colorectal polyps (94 neoplastic) in 66 patients (303 videos). The mean polyp size was 9.0 ± 8.1 mm and 54 polyps were non-polypoid. The mean polyp visibility scores for LCI (2.86 ±1.08) were significantly higher than for WL and BLI-bright (2.53 ±1.15, P < 0.001; 2.73 ± 1.47, P <0.041). The ratio of poor visibility (score 1 and 2) was significantly lower in LCI for experts and non-experts (35.6 %, 33.6 %) compared with WL (49.6 %, P = 0.015, 50.5 %, P = 0.046). The polyp visibility scores for LCI were significantly higher than those for WL for all of the factors. With respect to the comparison between BLI-bright and WL, the polyp visibility scores for BLI-bright were not higher than WL for right-sided location, < 10 mm size, sessile serrated adenoma and polyp histology, and poor preparation. For those characteristics, LCI improved the lesions with right-sided location, SSA/P histology, and poor preparation significantly better than BLI.

Conclusions: LCI improved polyp visibility compared to WL for both expert and non-expert endoscopists. It is useful for improving polyp visibility in any location, any size, any morphology, any histology, and any preparation level.


Endoscopic Submucosal Dissection of a Rectal Neuroendocrine Tumor Using Linked Color Imaging Technique.

Xiao-Tian Sun1, Min Min2, Yi-Liang Bi2, Yang Xu2, Yan Liu2

Chin Med J (Engl). 2017 May 5 Impact factor 0.957

Endoscopic submucosal dissection (ESD) has been widely applied in clinical practice for resecting gastrointestinal mucosal lesions. However, the risk of post-ESD complications is relatively high, and the bleeding is one of the most common complications after ESD, which needs timely detection and treatment. At recent, several new endoscopic imaging techniques have been developed to improve the diagnostic efficiency. Linked color imaging (LCI), which is a newly developed endoscopic technique,[1],[2] could enhance the color contrast and thus have advantage of identifying bleeding points during ESD. So far, whether the application of LCI in ESD procedure is feasible and safe has not been ever explored. In this report, we described a patient with rectal neuroendocrine tumor who was successfully treated by ESD using LCI.

The dissection was completed under WLE mode, which could clearly observe the mucosa and submucosal vessels. If the bleeding was suspected, LCI mode was used, which was easier to detect the bleeding point located in superficial submucosa [Supplementary Video 2]. The postoperative wound should be observed combining WLE and LCI mode, which could effectively handle the superficial and deep vessels and prevent postoperative bleeding.

This report demonstrated that LCI technique could be safe and effective in the application of ESD for rectal neuroendocrine tumor. LCI is a new endoscopic technique, which has a high diagnostic field. The report rarely demonstrated that the application of LCI during ESD was feasible and safe. Furthermore, the observation under LCI mode could identify the bleeding points, enabling the complete hemostasis. LCI mode is quite efficient in detecting the bleeding points during ESD, while WLE mode is recommended for the dissection procedure to avoid vascular damage. The clinical application of LCI might be further examined in future clinical trial.


Comparison of Linked color imaging and white-light colonoscopy for colorectal polyp detection: a multicenter, randomized, crossover trial.

Min M1, Deng P1 etc

Gastrointest Endosc. 2017 Mar 9. Impact factor 5.369

Background and Aims: Linked color imaging (LCI) is a recently developed technology that uses a laser endoscopic system to enhance the color separation of red color to depict red and white colors more vividly. The benefits of LCI in colorectal polyp detection remain unknown. The aim of this study was to assess the ability of LCI to increase colorectal polyp detection compared to white-light (WL) endoscopy.

Methods: We performed a multicenter, crossover, prospective, randomized controlled trial in three hospitals in China. All patients underwent crossover colonoscopies with LCI and WL endoscopy in a randomized order. All lesions were removed during the second endoscopic procedure. The primary outcome measure was the difference in sensitivity between LCI and WL endoscopy for the detection of colorectal polyps. The secondary outcome measures were the adenoma detection rate per patient in the two groups and the factors associated with polyp miss rates.

Results: A total of152 patients were randomized, and 141 were included in the analysis. The overall polyp detection rate increased significantly by 24% for LCI colonoscopy, corresponding to a higher sensitivity of LCI than WL endoscopy (91% vs 73%, P<0.0001). Furthermore, LCI identified significantly more patients (32%) with polyps. The per-patient adenoma detection rate was significantly higher for LCI than WL endoscopy (37% vs 28%, 95% CI, 2.39% – 19.41%).

Conclusion: LCI improves the detection of colorectal polyps and adenomas during colonoscopy.


Linked color imaging enhances gastric cancer in gastric intestinal metaplasia.

Ono S, Abiko S, Kato M. etc

Dig Endosc. 2017 Mar;29(2) Impact factor 2.715

Gastric intestinal metaplasia (GIM) is a high-risk condition for intestinal-type gastric cancer; however, there is a limitation for detection of GIMusing white light imaging (WLI). Image-enhanced endoscopy (IEE) is more advantageous than WLI for optical diagnosis of GIM.1 Linked colorimaging (LCI; FUJIFILM Co., Tokyo, Japan) was newly developed for advanced IEE and enables visualization of red lesions that appear redder and whitish red lesions that appear whiter during routine endoscopy.2 GIM is observed as a lavender color that is distinguishable from the circumferential mucosa without GIM by using LCI (Fig. 1). We speculate that the lavender color is the same as the bluish–whitish patchy areas including a light blue crest or a marginal turbid band in narrow band imaging.3,4 In contrast, gastric cancer is observed as lesions of various degrees of redness depending on the quantity of blood vessels.

Awoman in her 70s received screening esophagogastroduodenoscopy in the 7th year after Helicobacter pylori eradication. At first, neither abnormal lesions nor GIM were detected in the antrum by WLI, but a 10mm slightly reddish depressed lesion in a lavender color area was observed by LCI (Fig. 2a,b). A biopsy specimen from this lesion revealed well-differentiated tubular adenocarcinoma, and endoscopic submucosal dissection (ESD) was therefore carried out. Histologically, GIM surrounded the intramucosal adenocarcinoma (Fig. 2c,d).

The present case showed an important advantage of LCI during routine endoscopy. GIM, which is a high-risk condition for gastric cancer, was easily detected by LCI as a lavender color. Furthermore, LCI enhanced a gastric cancer in GIM. LCI would be a useful tool for detection of gastric cancer in high-risk patients.


Assessment of endoscopic mucosal healing of ulcerative colitis using linked colour imaging, a novel endoscopic enhancement system

Uchiyama K1, Takagi T1, etc.

J Crohns Colitis. 2017 Feb 22 Impact factor 6.585

Background and Aims: Mucosal healing and control of intestinal mucosal inflammation are important treatment goals for maintaining clinical remission in ulcerative colitis (UC) patients. Here, we investigated the efficacy of LCI, a novel endoscopic enhancement system, to diagnose mucosal inflammation in UC patients.

Methods: All examinations were carried out with a LASEREO endoscopic system (FUJIFILM Co., Tokyo, Japan). Fifty-two patients with UC were enrolled, and 193 areas assessed by LCI were examined. LCI patterns were classified as A, no redness; B, redness with visible vessels; and C, redness without visible vessels. ROI were set at biopsy sites, and red colour in the ROI was calculated as Commission internationale de l’éclairage (CIE) color space and digitized (LCI-index). Biopsy specimens were taken at each ROI and evaluated with Matts histopathological grade. Thirty months was defined as the time interval between endoscopic diagnosis and relapse of UC.

Results: Inter-observer agreement for LCI classification was excellent between an expert and non-experts. Among areas with a Mayo endoscopic subscore of 0, 41.8% and 4.6% were classified as LCI-B and C respectively. Among areas with Mayo endoscopic subscore of 1, 60.5% and 34.6% were classified as LCI-C, and B respectively. LCI-index strongly correlated with histopathological Matts score. Non-relapse rates significantly correlated with LCI classification (p=0.0055), but not with Mayo endoscopic subscore (p=0.0632).

Conclusions:Endoscopic LCI classification and LCI index can subdivide samples with the same Mayo endoscopic subscore. LCI may be a novel approach to evaluate colonic mucosal inflammation and predict outcome in UC patients.


Linked-color imaging improves endoscopic visibility of colorectal nongranular flat lesions.

Suzuki T, Hara T etc

Gastrointest Endosc. 2017 Feb 10. pii: S0016-5107(17)30088-3. Impact factor 5.369

Background and Aims: As a newly developed image-enhanced endoscopy (IEE) technique, linked-color imaging (LCI) provides very bright images with enhanced color tones. With the objective of improving the detection rate of colorectal flat tumor lesions, which are difficult to detect, we examined the usefulness of LCI from the viewpoint of visibility.

Methods: Fifty-three consecutive nongranular flat tumors were used in this study. Endoscopic images were acquired by white-light imaging (WLI), blue-laser imaging (BLI)-bright, and LCI modes. For each lesion, we selected one image each acquired by WLI, BLI-bright, and LCI modes. Six endoscopists interpreted the images. Using a previously reported visibility scale, we scored the visibility level on a scale of 1 to 4.

Results: The mean visibility scores were 2.74 ± 1.08 for WLI, 2.94 ± 0.97 for BLI-bright, and 3.36 ± 0.72 for LCI. The score was significantly higher for BLI-bright compared with WLI (p<0.001), and again higher for LCI compared with BLI-bright (p<0.001). When comparing between experts and trainees, the corresponding scores of experts were 2.83 ± 1.06, 3.17 ± 0.88, and 3.40 ± 0.74, with a tendency similar to the scores of all endoscopists. For the trainees, there was no difference between the scores for WLI (2.65 ± 1.10) and BLI-bright (2.71 ± 1.00), but the score for LCI (3.31 ± 0.69) was significantly higher than that for WLI or BLI-bright (p<0.001). When only sessile serrated adenoma/polyp (SSA/P) lesions were analyzed, LCI remained significantly higher than the other two.

Conclusions: The present findings suggest that LCI increases the visibility of colorectal flat lesions and contributes to improve the detection rate of these lesions.


Detectability of colorectal neoplastic lesions using a novel endoscopic system with blue laser imaging: a multicenter randomized controlled trial.

Ikematsu H, Sakamoto T

Gastrointest Endosc. 2017 Jan 29. Impact factor 5.369

Background and Aims: Most studies have not reported an improvement in the detection of adenomas with the use of image-enhanced colonoscopy methods, possibly because of the darkness of the images. To overcome this limitation, a new-generation endoscopic system has been developed. This system has 2 blue-laser imaging (BLI) observation modes. The BLI observation was set to BLI-bright mode to detect lesions. We aimed to evaluate the efficacy of BLI in detecting lesions.

Methods: This study was designed as a randomized controlled trial with participants from 8 institutions. We enrolled patients aged ≥40 years. The participants were randomly assigned to 2 groups: observation by using white-light imaging (WLI) with a conventional xenon light source (WLI group) or observation by using BLI-bright mode with a laser light source (BLI group). All of the detected lesions were resected or had a biopsy taken for histopathologic analysis. The primary outcome was the mean number of adenomas per patient (MAP) that were detected per procedure.

Results: The WLI and BLI groups consisted of 474 and 489 patients, respectively. The MAP was significantly higher in the BLI group than in the WLI group (mean ± standard deviation [SD] WLI 1.01 ± 1.36, BLI 1.27 ± 1.73; P = .008). Adenoma detection rate in the BLI group was not significantly higher than in the WLI group. Observation times differed significantly, with BLI (9.48 minutes) being longer than WLI (8.42; P < .001). The mean (± SD) number of polyps per patient was significantly higher in the BLI group compared with the WLI group (WLI 1.43 ± 1.64, BLI 1.84 ± 2.09; P = .001).

Conclusions: A newly developed system that uses BLI improves the detection of adenomatous lesions compared with WLI.